早期壓瘡的診斷和治療新進展

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早期壓瘡的診斷和治療新進展

常淑文,喬炎,束余聲

綜述了國內外壓瘡早期診斷、治療新進展，早期診斷方法包括早期炎性介質檢測法、皮膚溫度監測法、影像技術、局部血流監測等；早期治療及護理壓瘡的方法包括濕性敷料或蜂蜜醫用敷料應用、光線療法、自體脂肪組織移植法、集束化護理及綜合療法等。早期發現、早期干預可以降低壓瘡發生率、縮短治療時間、提高病人的生活質量。

壓瘡；早期診斷；早期治療；組織反射光譜法；炎性介質；皮膚溫度；影像技術；敷料

壓瘡又稱壓力性損傷(pressure injury,PI)，是2016年美國壓瘡咨詢委員會(National Pressure Ulcer Advisory Panel，NPUAP)關于壓瘡的最新定義，是指皮膚或皮下組織由于壓力或聯合有剪切力或(和)摩擦力作用而發生在骨隆突處的局限性損傷[1]。壓力可以導致組織缺血、炎癥性改變，損傷程度從皮膚壓紅到全層組織缺失后而暴露出肌肉、筋膜、骨骼等[2]。隨著人口老齡化的進展，壓瘡已成為一個越來越嚴重的慢性病并發癥[3]，如能早期發現、早期干預可使壓瘡的發病率大大降低。在對國內外文獻回顧的基礎上，旨在闡述關于壓瘡的早期診斷及治療方法的現狀，以期為醫護人員和照顧者早期發現壓瘡、早期干預提供參考。

1 壓瘡的流行病學調查

流行病學調查顯示：壓瘡的患病率在普通病房約為12%、急診病房約為23%[4-7]。2007年歐洲住院病人發病率為4.7%～32.1%，養老機構中發病率為22%[8]；Amir等[9]2016年調查總體發病率為8.0%、醫院內獲得性壓瘡為4.5%。英國的調查顯示：以壓瘡為主的慢性傷口治療每年花費3.28億英鎊，1例病人約1 727英鎊[10]。壓瘡不但延長住院時間、增加發病率和死亡率、降低生活質量[11]、影響病人康復，還會增加醫療成本[12]。因此，早預防、早發現、早治療是壓瘡護理的核心內容[13]。

2 早期發現、早期診斷的意義

荷蘭一項調查顯示約50%的壓瘡為Ⅰ期壓瘡[14]。Krishnan等[15]發現：約47%的病人是在急性住院期間或康復期間形成壓瘡，炎性介質能夠早期識別脊髓損傷病人壓瘡的發生，從而在壓瘡發生前即可初步確診；Ⅰ期壓瘡病人在所有壓瘡病人中所占比例較高，且大多數早期壓瘡會惡化成Ⅱ期或更嚴重階段[16]；Halfens等[17]通過對Ⅰ期壓瘡的早期干預使得發生率降低50%。綜合文獻可看出早期發現、早期診斷、早期治療對于疾病的康復和病人生活質量都有較大的改善[2-3,14,17]。

3 早期診斷方法

3.1組織反射光譜法(tissue reflectance spectroscopy,TRP) Riordan等[18]研究結果顯示：運用TRP進行早期壓瘡診斷，能夠在各種不同色素沉著的皮膚上進行反應性紅斑檢測，并具有較好的信效度。

3.2早期炎性介質檢測Krishnan等[15]在脊髓損傷病人中發現：若病人發生壓瘡則血漿中干擾素誘導蛋白-10 (IP-10)升高，而尿液中干擾素-α(IFN-α)下降；若未發生壓瘡則血漿中的粒-巨噬細胞集落刺激因子(GM-CSF)升高。針對這些炎癥因子的變化及時采取預防措施，可降低壓瘡的發生率。

3.3皮膚溫度變化有研究發現：手術時間較長的病人皮膚溫度會發生明顯變化，可使用溫度分布圖對病人受壓部位進行評價[19]。Nakagami等[20]使用熱成像儀器根據溫度變化對壓瘡傷口評估來預測創面愈合時間,并給予適當治療，可以降低壓瘡發生率。Fard等[21]開發一種連續的壓力和溫度監測系統，該系統設置了壓力和溫度報警設置，在壓瘡的早期診斷和預防上具有可行性。

3.4影像技術Marylou等[22]使用掃描電鏡發現壓紅或Ⅰ期壓瘡局部比正常人皮下水分含量增加，全身性水腫嚴重者高于無水腫者，進而說明表皮及皮下水分含量的變化可預測壓瘡發生，并作為診斷早期壓瘡的實驗基礎。

3.5皮膚鏡檢查Shigeki等[23]研究發現：早期壓瘡是一種混合性的壓紅，包括能夠緩解的壓紅(指壓變白)和不能緩解的(指壓不變白)。皮膚鏡下可見壓紅不緩解病人毛細血管持續存在擴張性條紋和紫癜，這些特點有助于壓瘡的早期診斷。

3.6血流監測激光多普勒血流儀(laser doppler flowmetry,LDF)是無創性皮膚血流監測工具[24]，應用LDF可對壓瘡高危病人進行血流檢測，并評估組織缺血的嚴重程度，可作為壓瘡風險評估的一種方法[25]。Liao等[26]關于大鼠壓力對皮膚血流的影響研究，使用LDF對負重缺血部位皮膚血液的排量波動監測(blood flow oscillations，BFO)顯示預測壓瘡是可行的。Chenu等[27]使用TexiCare系統對骶尾部進行血流監測，實時記錄和分析臀部的壓力變化并提出危險警告，可預防長期坐輪椅病人骶尾部壓瘡的發生。

4 早期壓瘡的治療及護理

4.1預防性皮膚護理保持皮膚完整是預防壓瘡的重要環節[28]，因此應早期實施預防性皮膚護理[29]。如盡可能避免使紅斑區域受壓的體位；使用pH值平衡的清潔劑；保持皮膚清潔干燥；不按摩或用力擦洗存在壓瘡風險的區域；實施個體化的大、小便失禁管理；避免皮膚暴露在過度潮濕的環境中；使用潤膚劑保持皮膚濕潤等[30]。同時注意控制微環境、使用預防性敷料、使用降低剪切力與摩擦力的紡織物[31]。

4.2縮短受壓時間預防壓瘡首先要降低壓力、摩擦力和剪切力[32],最常用的方法為變換體位。目前關于翻身時間間隔尚未明確，臨床中使用較多的是2 h翻身1次,可根據病人實際情況適當延長或縮短[33]。減壓床墊的使用可以減輕局部壓力的效果確切,已被廣泛用于預防壓瘡[34]。澳大利亞醫學研究顯示：羊皮是一種新型減壓工具，已被證實能有效降低病人壓瘡的發生[35]。

4.3外用藥物或敷料壓瘡愈合的關鍵因素是保持一個潮濕、閉合的傷口愈合環境[36]。有研究表明：濕性敷料(如聚合物泡沫敷料、水凝膠、藻酸鹽敷料、銀離子敷料、水凝膠敷料及生物膜等)有保護皮膚、抗菌或促進肉芽組織再生的功能，可降低壓瘡發生率，比傳統紗布敷料更有效[37-38]。Milne等[39]研究發現低pH值的敷料在傷口愈合過程中發揮作用較大。

4.4物理因子或光線療法紫外線(ultraviolet，UV)，尤其是短波紫外線(UVC,200 nm～280 nm)能夠殺滅細菌、真菌和病毒[40]，還能促進皮膚釋放免疫因子、加速組織修復及鎮痛等[41]。使用紫外線燈(254 nm)在小鼠三度燒傷皮膚照射治療證明紫外線照射可明顯降低燒傷創面真菌感染[40]。有研究表明：使用UVC治療后，創面面積縮小對創面愈合具有顯著療效[42-43]。Chen等[44]使用光線療法治療壓瘡,創面滲出減少、肉芽組織增生明顯，有助于縮短壓瘡愈合時間。

4.5自體脂肪組織移植隨著對脂肪再生性能的深入了解，目前已被引入到各個領域，包括壓瘡的防治。Marangi等[45]發現通過對移植區域和正常區域在皮膚厚度、筋膜完整性及皮下血管情況等方面進行比較，發現兩者在相關參數上是相似的，說明使用脂肪移植可有效治療早期壓瘡。

4.6集束化護理集束化護理即應用多個核心、有效的干預方法對病人進行綜合干預[46]，體現了措施的針對性、綜合性及科學性。如浮動床的使用、全身皮膚評估、皮膚潤滑、壓力再分配裝置的早期運用、體位變換等集束化護理的實施，可減少醫院獲得性壓瘡的發生[47]。 Vélez-Díaz-Pallarés等[48]總結了非藥物性綜合治療的研究主要集中在支撐面、營養、電療及其他輔助治療(超聲、負壓、激光、電磁或振動療法)，使用單獨一種非藥物治療對于創面愈合效果是不確定的，但多種方法的綜合治療可增加老年壓瘡病人的愈合率。

4.7改善營養狀況病人營養狀態與壓瘡的發生、發展和預后密切相關，如近期失重、低體重指數、蛋白質攝入減少、進食困難及低營養攝入者等[49-50]是發生壓瘡的高風險人群。因此，改善營養狀況、糾正低蛋白血癥是預防壓瘡的根本措施[50]。維生素A能夠刺激成纖維細胞促進膠原沉積，影響傷口愈合進程；維生素C影響結締組織蛋白的分泌、成纖維細胞增殖及血管形成，早期壓瘡病人建議每日服用維生素C 100 mg～200 mg，嚴重者1 000 mg～2 000 mg[51-52]；鎂是體內酶或其他蛋白、膠原形成、組織生長必需的輔因子,與三磷酸腺苷一起促進膠原合成；銅可加強膠原蛋白交聯,穩定膠原框架[53]；鋅主要參與DNA合成、細胞增殖和傷口愈合[51，54]。在壓瘡高危人群中予以補充適量的微量元素對于壓瘡的預防和發展有較大的改善作用。

4.8蜂蜜蜂蜜作為傷口愈合的佐劑已被使用了數百年，在傷口愈合中的主要作用機制包括抗菌能力、免疫調節和維持生理平衡等[55]。目前，已有醫用蜂蜜敷料應用于傷口護理，研究表明醫用蜂蜜敷料在急、慢性傷口和壓力性潰瘍等傷口管理上是安全、有效、低成本的治療方案[56]。

4.9醫護人員及照顧者的培訓醫務人員對于壓瘡風險評估的態度也影響壓瘡的發病率[57]，對醫護人員進行相關培訓可以提高判定壓瘡的準確率和界定壓瘡種類的正確率[58]，加強對照顧者的教育可影響壓瘡的發展和預后[59]。

5 小結

壓紅不緩解或Ⅰ期壓瘡的皮膚完整性未受損害，如及時采取措施去除病因，皮膚改變可恢復正常，也可防止壓瘡的進一步進展。因此，在護理工作中壓瘡的早期診斷、早期治療尤為重要。綜合文獻資料可見，早期診斷壓瘡方法主要集中在影像技術、受壓部位血流監測及炎性介質早期檢測等方面，如能廣泛使用簡單、易行、可視化的操作工具，對于高危人群進行診斷并早期使用保護性敷料，可以大大降低壓瘡的發病率，并能改善壓瘡高危者的生活質量。

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(本文編輯張建華)

Newprogressondiagnosisandtreatmentofearlypressuresores

ChangShuwen,QiaoYan,ShuYusheng

(School of Nursing,Yangzhou University,Jiangsu 225001 China)

It reviewed the new progress on early diagnosis and treatment of pressure sore at home and abroad.Early diagnostic methods included tissue reflex spectroscopy,early inflammatory mediators detection,skin temperature monitoring,imaging techniques and local blood flow monitoring.Early treatment and nursing methods of pressure sores included wet dressings or honey medical dressings applications,light therapy,autologous adipose tissue transplantation,cluster care and comprehensive therapy.Early detection,early intervention can reduce the incidence of pressure sores,shorten the treatment time and improve the quality of life of patients.

pressure sores；early diagnosis；early treatment；tissue reflectance spectroscopy；inflammatory mediators；skin temperature；image technology；dressing

常淑文,主管護師，碩士研究生在讀，單位：225001，揚州大學護理學院(225001，江蘇省蘇北人民醫院)；喬炎單位：399-4117，日本長野縣看護大學；束余聲(通訊作者)單位：225001，江蘇省蘇北人民醫院。

信息 常淑文，喬炎，束余聲.早期壓瘡的診斷和治療新進展[J].護理研究，2017，31(24)：2963-2966.

R472

：Adoi:10.3969/j.issn.1009-6493.2017.24.005

：1009-6493(2017)24-2963-04

2016-07-26；

2017-07-25)